Kansas City Cardiomyopathy Questionnaire (KCCQ-12)

The following questions refer to your heart failure and how it may affect your life. Please read and complete the following
questions. There are no right or wrong answers. Please mark the answer that best applies to you.

1. Heart failure affects different people in different ways. Some feel shortness of breath while others feel fatigue. Please
indicate how much you are limited by heart failure (shortness of breath or fatigue) in your ability to do the following
activities over the past 2 weeks.
Limited for
other reasons
Extremely Quite a bit Moderately Slightly Not at all or did not do
Activity Limited Limited Limited Limited Limited the activity

a. Showering/bathing O O O O O O

b. Walking 1 block on
level ground
O O O O O O

c. Hurrying or jogging
(as if to catch a bus) O O O O O O
1 2 3 4 5 6

2. Over the past 2 weeks, how many times did you have swelling in your feet, ankles or legs when you woke up in the
morning?
3 or more times
per week but Less than Never over the
Every morning not every day 1-2 times per week once a week past 2 weeks
O O O O O
1 2 3 4 5

3. Over the past 2 weeks, on average, how many times has fatigue limited your ability to do what you wanted?

3 or more times
All of Several times At least per week but 1-2 times Less than Never over the
the time per day once a day not every day per week once a week past 2 weeks
O O O O O O O
1 2 3 4 5 6 7

4. Over the past 2 weeks, on average, how many times has shortness of breath limited your ability to do what you
wanted?
3 or more times
All of Several times At least per week but 1-2 times Less than Never over the
the time per day once a day not every day per week once a week past 2 weeks
O O O O O O O
1 2 3 4 5 6 7

5. Over the past 2 weeks, on average, how many times have you been forced to sleep sitting up in a chair or with at
least 3 pillows to prop you up because of shortness of breath?

3 or more times
per week but 1-2 times Less than Never over the
Every night not every day per week once a week past 2 weeks
O O O O O
1 2 3 4 5

Rev. 2012-04-11
 KCCQ-12
Page 2 of 2

6. Over the past 2 weeks, how much has your heart failure limited your enjoyment of life?

It has extremely It has limited my It has moderately It has slightly It has not limited
limited my enjoyment enjoyment of life limited my enjoyment limited my enjoyment my enjoyment
of life quite a bit of life of life of life at all
O O O O O
1 2 3 4 5

7. If you had to spend the rest of your life with your heart failure the way it is right now, how would you feel about this?

Not at all Mostly Somewhat Mostly Completely

satisfied dissatisfied satisfied satisfied satisfied
O O O O O
1 2 3 4 5

8. How much does your heart failure affect your lifestyle? Please indicate how your heart failure may have limited your
participation in the following activities over the past 2 weeks.

Does not apply

Severely Limited Moderately Slightly Did not or did not do for
Activity Limited quite a bit limited limited limit at all other reasons
a. Hobbies, recreational
activities
O O O O O O

b. Working or doing
household chores
O O O O O O

c. Visiting family or
friends out of your O O O O O O
home
1 2 3 4 5 6

Rev. 2012-04-16